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Referrals passed 2025: 426

Goal 2026: 500

Referrals passed 2026: 160

Closed business 2026: $70,445

Electronic Application

APPLICATION

TO BE COMPLETED BY NEW MEMBER, CATEGORY CHANGES

Part I (Please answer all questions)

Date *

Chapter Name

Applicant's Name

First Name *

Last Name *

Business Name *

Address

Street Address *

City *

State *

Country *

Country

Postal Code

Membership *

Personal Membership

Company Membership

Business Phone *

Fax

Email *

Website

Describe Your Product or Service (be specific) *

Category Applied for *

Category Assigned by Membership Committee

REGISTRATION FEE: $100.00

Participation Fees: *

Option 1: $624.00 - Two Year Membership (represents a 44% Discount off Annual Fees)
Option 2: $399.00 - One Year Membership
Total Enclosed

(Registration Fee Plus One Option Above)

Sponsor's Name

Applicant's Signature *

Clear

*For mailed checks, please address to:

Hansa Workspace

505 Ellicott Street

Buffalo, NY 14203

Box #A25

Type of Payment *

Personal Check

Company Check

Cash

Credit Card

M/C

Visa

Amex

Discover

Card Holder's Name *

Card Number *

CVV Number *

EXP Date *

Amount *

$

Card Zip Code *

Cardholder's Signature *

Clear

UPON YOUR ACCEPTANCE TO QUALITY CONTACTS NY INC., FEES ARE NON-REFUNDABLE WITHOUT EXCEPTION

APPLICATION PROCESS

PART II (Please read carefully)

1. A prospective member may attend two meetings as a visitor. Prospective members then complete this application and submit it with payment to the Membership Committee for review.

2. The Membership Committee completes the screening process and notifies the prospective of acceptance or non-acceptance before the next meeting.

3. The Membership Committee notifies the Team Leader.

4. The Team Leader announces new members at chapter meeting following acceptance by the Membership Committee.

PART III (Please answer all questions)

Experience in Field/Occupation (be specific) *

Education background in Field/Occupation or Degrees, Licenses or Credentials required to perform in Field/Occupation *

PART IV

1. Is the occupation under which you are applying for membership a full or part-time occupation? *

FULL TIME

PART TIME

2. How long have you been with the company you are representing today? *

3. Are you able and willing to make the commitment to arrive at our weekly meetings, or virtual attendance, on time and stay throughout the 90 minutes, attend the Member Success Program Training and are you willing to abide by Policies, Guidelines & Code of Ethics? *

YES

NO

4. Have you been convicted of a felony? *

YES

NO

If YES please list:

5. All members are expected to contribute to the Chapter's management. What Leadership Team position interests you the most? *

TEAM LEADER

VICE PRESIDENT

SECRETARY/TREASURER

MEMBERSHIP COMMITTEE

GUEST HOST

EVENT PLANNING

UPON YOUR ACCEPTANCE TO QUALITY CONTACTS NY INC., FEES ARE NON-REFUNDABLE WITHOUT EXCEPTION

Upon acceptance, I agree to abide by the following Code of Ethics during the tenure of my participation in the organization.

I will provide the quality of services at the prices that I have quoted.
I will be truthful with the members and their referrals.
I will build goodwill and trust among members and their referrals.
I will take responsibility for following up on the referrals I receive.

Note: Professional standards outlined in a formal code of ethics supersede the above standards. *

By checking this box, I confirm that I have reviewed and accepted the Code of Ethics.

BUSINESS REFERENCES

PART V

List Business References:

(1) Name: *

Position: *

Business: *

Phone: *

Fax:

Business Relationship (describe): *

(2) Name:

Position:

Business:

Phone:

Fax:

Business Relationship (describe):

Applicant's Signature *

Clear

Note: You may attach resume or biography for additional information. Thank you.

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

UPON YOUR ACCEPTANCE TO QUALITY CONTACTS NY INC., FEES ARE NON-REFUNDABLE WITHOUT EXCEPTION

Office:

505 Ellicott Street Buffalo, N.Y, 14203

Call:

716-243-9003

Email:

[email protected]

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